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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES A4ENVIRONMENTAL HEALTH DIVISr N SAN JOAQUIN, PHONE (209)W-3420 P O BOX 2009, STOCKTON, CA 95201 PI'�IT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby arde to Ban Joaquin County for a permit to construct and/or Snatall the work herein described. This spplicatiom is made in compllsnce with San Joaquln County Ordlnenee No. 549 and 1862 and the Rules and Resulatlons of San Joaquin County Public Health BerYlces. aCe Job Address PoQT cdF 3TOCK-T City STD�TIO1tJ Lot Si se/Acreage ^' ��•5 Ac¢ES Owner's Noma pay, r of 5TOC1CTorJ Address ZZO\ wr3-c W�1541J GToaPhons(Z� 946 0246 SIC.rJr1,- {-Ir,t_ CR to Conhacta �¢r C- I N5 1-1-J Address Z4 CF-QetToS `Sc License No.92�do3230 Phone3 427 0919 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Il DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ CPT f Ilw. ,-tQTHER X Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES `1APC5 DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL i WIF OTHER WELL±A-EC--S PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bonam ❑ Manteca Dia. of Well Excavation Dia. of Wen Casing Cl Domesuc/Private ❑ Gf" Pack O Tracy Type of Casing Specifications I'I Public Xothe, /Xpelta Depth of Grout Seal Type of Grout Vouc..aq I I Imoat,cn _Approx. Depth I I Eastern Surface Seel Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material t,Depth Depth Filler Naterial i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public Bawer a available within 200 feet.) Installation will serve: Residence _ Commercial _ Other Number of living unite _ Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nosiest: Well Foundation Property Lina LEACHING LINE ❑ No. 8 Length of lines Total length/sae FILTER BED ❑ Distance to nearest: Wall Foundation Property Line SEEPAGE PITS It Depth Sire Number SUMPS IJ Distance to nearest: Was Foundation Property Line DISPOSAL PONOS ❑ I hereby comity that I have prepared this appl¢ation and that the work will be done in accordance with San Joaquin county ordinances, state Laws, and rules and regulations of the San Joaquin County Home owner or licensed agent's signature cei the following. -I comity that in the performance of the work for which this permit is issued. I snarl not employ any person in such manner as to became subject to workman's Compensation laws of California ' Convector's hiring or sub-contracting signature candies the following: -I certify that in the paAamanca of the work for which this permit a issued, 1 shall employ persons subject to workman's compensa. tion Laws of Cajifoonw." The applicant mus can for required inspections. Complete drawing on reverse side. Signed X_L.1 ��.✓ 4—v Title: S y/)GG Data: //-/0-4? FOR DEPARTMENT USE ONLY Application Accepted by r "" "� DataArea Pit or Grout Inspection by //�� Oats Final nspectbn�byl Additional Comments: 6c,/�o Z_ C�_,/J ' �N- 7z,7,3 Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services pL 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. INFO (� -r/ . im,3.34 IAfV.r r-er 0� °�% � ooiq lq fN tams l